The Rituals Of American Hospital Birth
Why is childbirth, which should be such a unique and individual experience for women, treated in such a highly standardized way in the United States? No matter how long or short, how easy or hard their labors, the vast majority of American women are hooked up to an electronic fetal monitor and an IV, are encouraged to use pain-relieving drugs, receive an episiotomy, and are separated from their babies shortly after birth. Most of them also receive doses of the synthetic hormone Pitocin to speed their labors and give birth flat on their backs. More than one-third of all babies in the United States are delivered by cesarean section.
Many Americans, including most of the doctors and nurses who attend birth, view these procedures as medical necessities. Yet mothers in many low-technology cultures give birth sitting, squatting, semi-reclining— all positions far more physiologically efficacious—and are nurtured through the pain of labor by experienced midwives and supportive female relatives. What, then, might explain the standardization and technical elaboration of the American birthing process?
One answer emerges from the field of symbolic anthropology. Early in the 20th century, Arnold van Gennep noticed that in many societies around the world, major life transitions are ritualized. These cultural rites of passage make it appear that society itself effects the transformation of the individual. Could this explain the standardization of American birth?
I believe the answer is yes.
I came to this conclusion as a result of a study I conducted of American birth between 1983 and 1991. I interviewed more than 100 mothers and many of the obstetricians, nurses, childbirth educators and midwives who attended them. I realized that American society’s deepest beliefs center around science, technology, patriarchy and the institutions that control and disseminate them, and that there could be no better transmitter of these core values and beliefs than the hospital procedures so salient in American birth.
Rites of Passage
A ritual is a patterned, repetitive and symbolic enactment of a cultural belief or value; its primary purpose is alignment of the belief system of the individual with that of society. A rite of passage is a series of rituals that move individuals from one social state or status to another.
Rites of passage generally consist of three stages, originally outlined by van Gennep: 1) separation of the individuals from their preceding social state; 2) a period of transition in which they are neither one thing nor the other; and 3) an integration phase in which, through various rites of incorporation, they are absorbed into their new social state.
In the year-long pregnancy/childbirth rite of passage in American society, the separation phase begins with the woman’s first awareness of pregnancy; the transition stage lasts until several days after the birth; and the integration phase ends gradually in the newborn’s first few months of life.
By making the naturally transformative process of birth into a cultural rite of passage, a society can ensure that its basic values will be transmitted to the three new members born out of the birth process: the new baby, the woman reborn into the new social role of mother, and the man reborn as father.
The Characteristics of Ritual
The following primary characteristics of ritual are particularly relevant to understanding how the initiatory process of cognitive restructuring is accomplished in hospital birth.
Symbolism. Rituals transmit their meaning through symbols. A symbol is an object, idea or action that is loaded with cultural meaning. Instead of being analyzed intellectually, a symbol’s message will be felt through the body and the emotions. Thus, even though recipients may be unaware of incorporating the symbol’s message, its ultimate effect may be extremely powerful.
Routine obstetric procedures are highly symbolic. For example, to be seated in a wheelchair upon entering the hospital, as many laboring women are, is to receive through their bodies the symbolic message that they are disabled; to then be put to bed is to receive the symbolic message that they are sick. One woman told me, “I can remember just almost being in tears by the way they would wheel you in. I would come into the hospital, on top of this, breathing, you know, all in control. And they slap you in a wheelchair! It made me suddenly feel like maybe I wasn’t in control any more.”
The intravenous drips commonly attached to the hands or arms of birthing women make a powerful symbolic statement: They are umbilical cords to the hospital. By making her dependent on the institution for her life, the IV conveys one of the most profound messages of her initiation experience: In the contemporary American technocracy, we are all dependent on institutions for our lives, “umbilically” linked to them through the water and sewer pipes, electrical wires, and TVs that pervade our homes, through our banking accounts and credit cards, and increasingly through our laptops, cellphones, iPads and the like. The rituals of hospital birth are not accidental—they are profound symbolic and metaphoric expressions of technocratic life.
A cognitive matrix. A matrix (from the Latin mater, or mother), like a womb, is something from within which something else comes. Rituals are not arbitrary; they come from within the belief system of a group. Their primary purpose is to enact and thereby transmit that belief system into the emotions, minds and bodies of their participants. Thus, analysis of a culture’s rituals can lead to a profound understanding of its belief system.
A technocracy, as I define it, is a society organized around an ideology of progress through the development and increasing utilization of high technology and the global flow of information. Analysis of the rituals of hospital birth reveals their cognitive matrix to be the technocratic model of reality that forms the philosophical basis of both Western biomedicine and American society.
The technocratic model’s early forms were developed in the 1600s by Descartes, Bacon and Hobbes, among others. This model assumes that the universe is mechanistic, following predictable laws that the enlightened can discover through science and manipulate through technology, in order to decrease their dependence on nature. In this model, the human body is viewed as a machine that can be taken apart and put back together to ensure proper functioning. In the 17th century, the practical utility of this body-as-machine metaphor lay in its separation of body, mind and soul. The soul could be left to religion, the mind to the philosophers, and the body could be opened up to scientific investigation.
The metaphor of the body-as-machine was central in the development of modern obstetrics. Wide cultural acceptance of this metaphor accompanied the demise of the midwife and the rise of the male-attended, mechanically manipulated birth. The rising science of obstetrics adopted the assembly-line model of production of goods as its template for hospital birth. Accordingly, a woman’s reproductive tract came to be treated like a birthing machine by skilled technicians working under relatively inflexible timetables to meet production and quality-control demands. As one resident explained, “There is a set, established routine for doing things, usually for the convenience of the doctors and the nurses, and the laboring woman is someone you work around, rather than with.”
The most desirable end product of the birth process is the new social member, the baby; the new mother is a secondary by-product.
Repetition and redundancy. Ritual is also marked by repetition and redundancy. For maximum effectiveness, a ritual concentrates on sending one basic set of messages, repeating it over and over again in different forms.
In hospital birthing, the message is repeatedly conveyed that the laboring woman is dependent on the institution. She is also reminded in myriad ways of the potential defectiveness of her birthing machine. These include periodic and sometimes continuous electronic monitoring of that machine, frequent manual examinations of her cervix to make sure that it is dilating on schedule, and, if it isn’t, administration of the synthetic hormone Pitocin to speed up labor so that birth can take place within the standard 12 to 24 hours. These procedures repeatedly convey the messages that time is important, you must produce on time, and you cannot do that without technological assistance because your machine is defective.
When humans are subjected to extremes of stress and pain, they may become unreasonable and out of touch with reality. Ritual assuages this condition by giving people a conceptual handle to keep them from “falling apart” or “losing it.”
Labor subjects most women to extremes of pain, which are often intensified by the alien and frequently unsupportive hospital environment. They look to hospital rituals to relieve the distress resulting from their pain and fear. One woman expressed it this way: “I was terrified when my daughter was born. I just knew I was going to split open and bleed to death right there on the table, but she was coming so fast, they didn’t have any time to do anything to me…. I like cesarean sections, because you don’t have to be afraid.”
When you come from within a belief system, its rituals will comfort and calm you.